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The Policy VaultThe Policy Vault

Otezla — Blue Cross Blue Shield of Montana

plaque psoriasis (PS)

Initial criteria

  • Initial approval requires ALL of the following:
  • 1. Continuation of therapy pathway: patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed (samples not approvable) OR new start pathway per criteria below.
  • For psoriatic arthritis (PsA):
  • • Diagnosis of active PsA AND ONE of the following:
  • – Patient has stage IV metastatic cancer and requested agent is used to treat the cancer or an associated condition, AND use is consistent with best practices and FDA-approved indications; OR
  • – Patient has tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, or sulfasalazine) after ≥3 months of therapy; OR
  • – Patient has intolerance or hypersensitivity to ONE conventional agent used in PsA; OR
  • – Patient has FDA labeled contraindication to ALL conventional agents; OR
  • – Patient’s medication history shows use of another biologic immunomodulator FDA labeled or compendia supported for PsA.
  • For plaque psoriasis (PS):
  • • Diagnosis of plaque psoriasis AND BOTH of the following:
  • – Adults: mild to severe plaque psoriasis; OR pediatric patients age ≥6 years with moderate to severe plaque psoriasis and weight ≥20 kg; AND
  • – ONE of the following:
  • ▪ Stage IV metastatic cancer with same criteria as above; OR
  • ▪ Tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar, cyclosporine, methotrexate, pimecrolimus, PUVA phototherapy, tacrolimus, tazarotene, topical corticosteroids) after ≥3 months; OR
  • ▪ Intolerance or hypersensitivity to ONE conventional agent used in PS; OR
  • ▪ FDA labeled contraindication to ALL conventional agents; OR
  • ▪ Medication history shows use of another biologic immunomodulator agent FDA labeled or compendia supported for PS.
  • For Behcet’s disease (BD):
  • • Diagnosis of BD with active oral ulcers AND:
  • – ≥3 occurrences of oral ulcers in the last 12 months; AND
  • – ONE of the following:
  • ▪ Stage IV metastatic cancer pathway as above; OR
  • ▪ Tried and had inadequate response to ONE conventional agent (topical oral corticosteroids such as triamcinolone dental paste, or colchicine); OR
  • ▪ Intolerance or hypersensitivity to ONE conventional agent used in BD; OR
  • ▪ FDA labeled contraindication to ALL conventional agents; OR
  • ▪ Medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for BD.